The
following information explains the purpose of various kinds of advanced
directives used in North Carolina. In general, the Health Care Power of Attorney and the Living
Will are not honored by EMS because there is very little time
in a life or death situation to: 1) determine the validity of such advanced
directives and 2) thoughtfully read the advanced directive to determine what
lifesaving measures a patient wishes to have withheld. A valid North Carolina Do
Not Resuscitate (“DNR”) Orderis the only advanced directive that
will be honored by ICEMS personnel in the out-of-hospital setting.

Purpose:

·To educate EMS personnel about the
different types of advanced directives.

·Assure that ethically and legally
appropriate care is provided to patients with advanced directives.

Procedure:

1.Do Not Resuscitate Order1:“What is a
DNR order?” A DNR order allows the patient, or a
patient’s representative, to refuse attempts at CPR when the patient has
stopped breathing and/or the patient’s heart has stopped beating. The DNR
Order, written by the physician on a special goldenrod colored form with a
bright red stop sign, instructs healthcare providers to withhold CPR and other
heroic measures. This does mean that all care stops. If the patient requires
emergency care other than CPR (such as treating injuries, etc.) or “comfort
care” (making the patient as comfortable as possible), EMS will provide such
services. “How does a patient get a DNR order?”Generally, a
doctor writes a DNR order for patients who are terminally and incurably ill, or
in a persistent vegetative state, and who do not want their life needlessly
prolonged by resuscitation efforts. “What
happens if a patient has a DNR order?” A DNR order should
be kept with the patient. If the patient is at home or in a nursing home, and
his/her heart stops beating or he/she stops breathing, the DNR order will tell
EMS Personnel not to resuscitate the patient. Of course, if the patient has a
DNR order, EMS should not be called in the first place. However, family members
sometimes panic and call for help when they see their loved one in distress. The
DNR order helps make sure that the patient's wishes are honored. “What
happens if a patient doesn't have a DNR order?”If a
patient’s heart stops beating or he/she stops breathing and EMS is called, EMS
will resuscitate the patient if he/she does not have a DNR order. For many
people, this is a good thing because they recover and go on to live long and
productive lives. Unfortunately, some people may end up on life support systems
with no reasonable hope of recovery, and their families may question why they
were resuscitated. “What if there is a dispute
among family members about resuscitation and the patient has a valid DNR?” The
state has issued a new DNR form that is backed by legislation that protects
responders from liability if they do not act to resuscitate someone with a valid
DNR form.If EMS personnel encounter a
patient with an old DNR form, they will be compelled to initiate resuscitative
measures if the family is at odds with one another about resuscitation. It
is the duty of EMS to resuscitate patients whom they are called to help. Unless
the patient has a DNR order, or is obviously dead, EMS must try to
resuscitate the patient.(See Attachment # ___ for sample DNR forms).

2.Health Care Power of Attorney2:
“What is it?” A health care power of attorney is a document that
allows an individual to make medical decisions for someone if he/she cannot make
them his-/herself. The grantee must sign the document in the presence of two
qualified witnesses, and it must be notarized (see the form provided by Section
32A-25, North Carolina General Statutes, Attachment # ___ ). Other forms may be
used as long as they comply with the requirements of the statute. “Who may
be appointed?” Any competent person who is at least 18 years old and who
is not providing paid health care to the grantee. The person appointed is
referred to as the health care agent. “How much authority does it
give the health care agent?” The health care agent can have the same power
and authority as the grantee to make medical decisions. This includes the power
to consent to a physician giving, withholding, or stopping any medical
treatment, service or diagnostic procedure, including life-sustaining
procedures. The grantee may limit the health care agent's power. When is it
effective? A health care power of attorney is effective when a physician
states in writing that the grantee lacks sufficient understanding or capacity to
make or communicate health care decisions. “What happens if the health care
agent is unable or unwilling to act?” If the health care agent dies or
becomes sick or incapacitated, or if he or she simply refuses to act, the health
care power of attorney will have no legal effect. To avoid this problem, the
grantee may name one or more substitute health care agents. The substitute
health care agents will serve in the order listed in the health care power of
attorney.

Living Will3: “What
is a Living Will?” A living will is a person’s declaration that he/she
desires to die a natural death and does not want extraordinary medical treatment
or artificial nutrition or hydration used to keep him/her alive if there is no
reasonable hope of recovery. A living will gives the patient’s doctor, but
not EMS, permission to withhold or withdraw life support systems under certain
conditions. Everyone has a basic right to control the decisions about
his/her medical care, including the decision to have extraordinary means or
artificial nutrition or hydration withheld or withdrawn if his/her condition is
terminal and incurable or in a persistent vegetative state. “What is the difference between a living will and a DNR
order?”A living
will is a patient's decision not to have his life prolonged by artificial
means when there is no reasonable hope of recovery. Healthy people often have a
living will because it allows them to make this decision in advance. The patient
uses the living will to express his wishes about the end-of-life-care he wants. A
DNR order, on the other hand, is a medical order issued by the patient's doctor
after it has been determined that the patient is dying or in a persistent
vegetative state. He/she does not want to be resuscitated in the event
his/her heart stops beating or if he/she stops breathing because such an action
would only needlessly prolong his/her life. A DNR order is often initiated after
the doctors have determined that a patient's living will should be honored.
However, a patient does not need to have a living will before a DNR order can be
entered, although having a living will may simplify the process of obtaining a
DNR order. A living will and a DNR order are different documents that can work
together, but one is not dependent upon the other.